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Questions?
Check out your provider manual. Or contact us.
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Tips for requesting prior auth
A request for prior auth doesn’t guarantee payment. We can’t reimburse you for unauthorized services. You can make requesting prior auth easier with these tips:
- Register for Availity if you haven’t already.
- Verify member eligibility before providing services.
Based on the type of request, complete and submit the prior auth request form.
Attach supporting documents when you submit the form.
Types of prior auth request forms
How to request prior auth
By phone
Ask for prior auth by calling us:
Medicaid Managed Medical Assistance: 1-800-441-5501 (TTY: 711)
Florida Healthy Kids: 1-844-528-5815 (TTY: 711)
By fax
Download and complete the prior auth request form based on the type of request. Add any supporting materials for the review. Then, fax it to us.
Fax numbers for prior auth request forms
Physical health prior auth request form fax: 1-860-607-8056
Behavioral health prior auth request form fax (Medicaid Managed Medical Assistance): 1-833-365-2474
Behavioral health prior auth request form fax (Florida Healthy Kids): 1-833-365-2493
Utilization management (UM)
The purpose of UM is to review eligibility for benefits for the care that has been or will be provided to patients. The UM department is composed of:
Preauthorization
Concurrent review
Case management
Medical necessity is based upon clinical standards and guidelines as well as clinical judgment. All clinical standards and guidelines used in the UM program have been reviewed and approved by practicing, participating physicians in our network.
Need a copy of our clinical standards and guidelines? Just call us at 1-800-441-5501 (TTY: 711), 7:30 AM to 7 PM, Monday through Friday.
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The medical director makes all final decisions regarding the denial of coverage for services when the services are reviewed via our UM program. The provider is advised that the decision is a payment decision and not a denial of care. The responsibility for treatment remains with the attending physicians.
The policy on payment for services helps ensure that the UM decision-making process is based on consistent application of appropriate criteria and policies rather than financial incentives.
UM decision-making is based on:
Appropriateness of care
Service
Existence of coverage
Adverse decisions
The medical director is available to discuss denials with attending physicians and other providers during the decision process. Notification of the decision includes:
The criteria used and the clinical reason(s) for the adverse decision
Instructions on how to request reconsideration
A contact person’s name, address and telephone number for requesting reconsideration
We do not reward practitioners, providers or employees who perform utilization reviews, including those of the delegated entities, for issuing denials of coverage or care. The compensation that we pay to practitioners, providers and staff assisting in utilization-related decisions does not encourage decisions that result in underutilization or barriers to care or service.
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Want to learn more? You can contact our UM staff if you need help or have any questions related to a specific case. You can get help 8 AM to 7 PM, Monday through Friday.
Medicaid Managed Medical Assistance: Call 1-800-441-5501 (TTY: 711)
Long-Term Care: Call 1-844-645-7371 (TTY: 711)
Florida Healthy Kids: Call 1-844-528-5815 (TTY: 711)
For questions after hours or during weekends or holidays, just leave a voicemail or fax. We’ll return your message.
Pharmacy prior auth
Want to learn more about pharmacy prior auth? Just visit our pharmacy prior auth page.